Neuroradiology
The historical events in neuroimaging and vascular intervention narrated by Vedula
Rajainikanth Rao and Ravi Mandalam Kolathu in the current issue[1]
[2] took place in the erstwhile Sree Chitra Tirunal Medical Centre (Chitra), Thiruvananthapuram.
In the 1970s, it was a hospital with 120 beds under the Government of Kerala, but
stood apart by being sponsored by the Department of Science and Technology of Kerala,
mandating the hospital to provide clinical inputs for medical technology development
from their services, which were offered only to referred cardiology and neurology
patients(►[Fig. 1]). The hospital opened its doors to patients in 1976 and Professor Mahadevan Pillai
joined as head of the Radiology Department. A pioneer who had trained under masters
like Seldinger played a major role as a founder of neuroradiology while serving in
the Barnard Institute, Chennai, and National Institute of Mental Health and Neurosciences
(NIMHANS), Bangalore. He was a brilliant radiologist, innovator, and a splendid colleague
whose friendliness was infectious! VRK Rao joined him in 1977 and Ravi Mandalam soon
after. Their main equipment was a Diagnost 77, Philips unit for myelography, and general-purpose
radiography. I remember Professor Pillai’s unique description of an in-house designed
and built manual changer of cassettes for serial angiography. Rao was a quick learner
and soon became the highly skilled partner of Professor Pillai. To perform percutaneous
carotid angiography with our equipment demanded ingenuity. It was indeed daring and
was further tested when simultaneous injections of both carotid arteries were done.
This obtained images in the axial view, enabling assessment of the lateral extent
of intrasellar pituitary tumors. This was of special interest to Professor George
Mathew who greatly valued the contributions of neuroradiology to expand his transsphenoidal
approach to the pituitary. The angiographic procedures were improved by locally developed
methods of magnification and subtraction, which were a notable example of frugal innovation
or Indian jugaad! Soon a Mimer III—Elema Schonander—was added to the armamentarium, which became the
workhorse of angiography and tomography. This was followed by a 70 mm camera, roll
film, and a Newton Hastystereotome. As the power of machines grew, human mind kept
pace as Professor Pillai taught Rao how to obtain stereoscopic vision by training
the position of both eyes while focusing on the object of interest to bring out a
third image! Mimer III made pneumoencephalography a routine procedure. The addition
of cerebral ventriculography using Conray 280, myelography employing Amipaque, and
air myelography expanded the range of diagnostic studies in Chitra, which attracted
the favorable notice of peers and drew patients in increasing numbers to the hospital.
Fig 1. A beautiful wooden staircase in the Satelmond Palace, gifted by His Excellency Marthanda
Varma for the research and development at the institute. Image courtesy: Mr Joy Vithayathil,
Senior Librarian, SCTIMST, Trivandrum.
Rao’s description of balloon angioplasty being preferred to surgical angioplasty of
subclavian artery is etched in my mind. It reminded me of John Hunter’s prescient
observation in the 18th century that a surgical operation is “like an armed savage
trying to get by force what a civilised man would get by stratagem.” It was natural
that interventional radiology grew rapidly at Chitra with the energetic pursuit of
new stratagems by Rao and Ravi Mandalam. Occlusive disease of peripheral arteries
caused by atherosclerosis in the old and by aortoarteritis in the young underwent
balloon angioplasty. The Chitra team acquired valuable experience and learnt important
lessons that were reported in scientific journals. Their appetite for novel techniques
was insatiable. An example was the effort to develop neodymium-doped yttrium aluminum
garnet laser to bore a channel in a totally occluded artery, followed by balloon angioplasty.
Though this was done successfully in experimental animals and one patient, the technique
was soon superseded by better methods. Ravi Mandalam went further and took the initiative
to develop implantable “spring coils” (anticipating stents) and the team even made
efforts to develop a “self-expandable stent.”
Interventional Neuroradiology
In part II, the authors give a detailed account of their effort to develop interventional
neuroradiology. Angiography had already shown that cerebral aneurysms were common
and the presence of two neurosurgeons—Professors George Mathew and Damodar Raut—who
had special interest in the treatment of aneurysms attracted increasing number of
patients. Arteriovenous malformations (AVMs) were less frequent and Professor Mathew
agreed with Rao that large AVMs would be suitable for management by embolotherapy
using crushed muscle, dura, or silastic microspheres developed by Dr. Jayakrishnan
of the Technology Wing of Chitra Institute. The techniques were successfully developed,
used, carefully followed up, and later reported. French Professors Lucien Picard and
Jack Moret were deeply impressed by the ongoing work at Chitra and provided crucial
assistance in initiating endovascular treatment for AVMs, additionally donating catheter
delivery systems. The successful management of large AVMs was performed side by side
with super selective angiography of the branches of middle cerebral and other crucial
arteries for occlusion. This would block the feeders to the AVM and facilitate surgery
with reduced blood loss. More than 150 superselective procedures were done with partial
obliteration of the AVM and radioanatomic cure obtained in more than 50% of patients.
Postdoctoral Training
The entire program in vascular and neuroradiology provided an opportunity for training
in the new discipline of interventional radiology. A 1-year Post Doctoral Certificate
Course was initiated in Chitra Institute with excellent response. Those who underwent
this training serve across India, occupying high faculty positions and heading departments
in major hospitals.
Conclusion
Sree Chitra Tirunal Medical Centre became an Institute of National Importance by an
Act of Parliament in 1980 to promote the joint culture of medicine and technology
for advancing health care. While its hospital sought to promote high quality service,
it was also mandated to deliver clinical inputs for developing instruments and devices
indispensable for the practice of medicine. The historical events at Chitra demonstrated
that the joint culture of medicine and technology is the precursor of new instruments
and devices, currently imported at high cost. To make high technology devices affordable
and accessible to common people, pursuit of frugal innovation as outlined in these
papers is necessary, inescapable, and commendable.
